Provider Demographics
NPI:1083600464
Name:WILCOX, STEPHAN J (RPH)
Entity Type:Individual
Prefix:MR
First Name:STEPHAN
Middle Name:J
Last Name:WILCOX
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:140 EAST RD
Mailing Address - Street 2:
Mailing Address - City:DIMONDALE
Mailing Address - State:MI
Mailing Address - Zip Code:48821-8705
Mailing Address - Country:US
Mailing Address - Phone:517-646-9274
Mailing Address - Fax:517-646-9278
Practice Address - Street 1:140 EAST RD
Practice Address - Street 2:
Practice Address - City:DIMONDALE
Practice Address - State:MI
Practice Address - Zip Code:48821-8705
Practice Address - Country:US
Practice Address - Phone:517-646-9274
Practice Address - Fax:517-646-9278
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5302411063183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist